Neurology Workforce Shortage: What Leaders Must Do Now to Avoid Crisis FOCUS PAPER Kim Blasingame, FACMPE September 20, 2018 This paper is submitted in partial fulfillment of the requirements of Fellowship in the American College of Medical Practice Executives Neurology Workforce Shortage: What Leaders Must Do Now to Avoid Crisis I. INTRODUCTION These are exciting times for neurology! Every year new treatments are brought to market. Neurologists and their care teams have more options to offer people affected by neurological conditions. People whose lives and futures are impacted and even devastated by multiple sclerosis, Parkinson’s disease, and migraine have new hope. Accompanying new treatments is an increasing demand for neurology services. As baby boomers age, the number of people affected by neurological conditions grows. Alzheimer’s disease, dementia, and stroke most commonly affect people over age 65. The neurology workforce is also aging. Every year baby boomer neurologists are reaching the age of retirement. There are not enough physicians and advanced practice providers in the neurology workforce or the training pipeline to meet the growing demand for their services. Medical groups and health systems are forced to compete ever more intensely to recruit qualified candidates to fill neurology provider positions. Neurology faces a future of spiraling demand combined with constrained supply. This threatens a public health crisis. What went wrong? What must be done? Page 1 of 25 II. RESEARCH METHODOLOGY The author’s 25 years of experience as a neurology practice administrator augmented an in-depth review of various publications, articles, and studies. Interviews were conducted with practicing neurologists (9,10), a regional director of a healthcare recruiting firm (11), and primary care physicians who are leaders of accountable care organizations (6,7). III. PURPOSE OF THIS PAPER The purpose of this paper is to examine the root causes of the neurology workforce shortage and to propose strategies to address the growing crisis. IV. BACKGROUND The demand for neurology services is increasingly outpacing the supply of clinicians who can provide them. Physician practices and health systems across the nation are experiencing growing competition for neurologists. Hiring neurology trained advanced practice providers (nurse practitioners and physician assistants) is challenging. A 2013 study supported by the American Academy of Neurology (AAN) showed an 11% shortage in neurologists at that time and projected a 19% shortage by 2025. The supply of neurologists is projected to increase from 16,366 in 2012 to 18,060 by 2025, while the demand is projected to increase from 18,180 in 2012 to 21,440 by 2025 (1). The generally accepted standard of care for wait time to see a neurologist is two weeks. The 2012 national average neurologist reported patient wait time for first appointment was 35 days (2). Page 2 of 25 In 2016, the average wait time to see a specialist in Parkinson’s disease was greater than two months, with one-third of centers reporting wait times greater than three months (3). Online research reveals countless individual reports of appointment wait times of many months for the most common neurologic conditions. Factors on both sides of the supply and demand equation contribute to this imbalance. A. Supply Constraints A fundamental catalyst of supply constraint in the physician workforce is an outdated system of government incentives. This is compounded by changes in neurology workforce demographics and worker’s expectations. U.S. government involvement with the supply of physicians began with the birth of Medicare in 1965. Policymakers took a forward-thinking approach to health insurance for the growing population of Americans over age 65 who could not access private insurance. The Medicare program included temporary funding for graduate medical education (GME) to strengthen the training pipeline of physicians to provide care to the newly insured. This GME funding was intended to be temporary, but it grew for the next 30 years, as did the supply of trained physicians. In 1997, amid concern for the financial impact of this program, the number of funded training institutions and positions was essentially frozen at 1996 levels. Annually, $15 billion of U.S. taxpayer dollars now support GME positions for primary care and specialties nationally. The Medicare program remains the primary source of GME funding (4). Page 3 of 25 More than 20 years have passed since 1996, bringing unprecedented advances in technology and treatment to the field of neurology. During this period, the site of care for most healthcare services continued to change. GME funding and the site of training did not. While the site of care for most healthcare services shifted away from teaching hospitals, training dollars did not. The structure of the government GME funding system discourages teaching hospitals from using training sites outside the hospital to better prepare physicians for the way they will practice medicine after training. The result: Physicians who will enter the workforce to practice in sites of care outside the hospital are trained in the hospital. They are poorly prepared for a world where payers and employers will demand that physicians keep patients out of the hospital to control cost. There is a skills gap in the transition from training to practice. The neurology workforce, already restricted by funding policy, is made less productive by the rough transition from training to practice. Productivity is further impacted by changes in the workforce itself. Neurologists under the age of 38 in 2018 are ‘millennials’ with different work-life priorities than older neurologists. The result is they work fewer hours and see fewer patients. This diminishes the impact of young neurologists entering the workforce. The increase in women entering the physician workforce reflects our changing culture, but is another factor reducing supply. Many in this growing population of female physicians continue to carry the role of primary provider of child care and family care, despite their professional position. The result is they work fewer hours and see fewer patients. The aging and retiring of the existing baby boomer neurology workforce compounds the shortage. As the supply of baby boomer neurologists declines, neurology groups and health systems pay higher compensation to younger neurologists for fewer work hours. While the work-life balance Page 4 of 25 shifts and compensation for young neurologists increases, the challenges of delivering neurology increase as well. A powerful solution to the shortage of neurologists is innovation in the use of advanced practice providers (APPs). APPs, including nurse practitioners and physician assistants, are an integral part of the team in primary care and other specialties. In neurology, this proven approach is impeded by a lack of training incentives, fee-for-service payer policies, negative attitudes by neurologists toward the team care approach, force of habit in the practice of neurology, and delayed adoption by neurology’s largest trade association. A regional director of a healthcare recruiting firm reported that APPs with neurology specific experience are even more difficult to recruit than neurologists (11). The root causes of the APP shortage, however, are less complex. Of the $15 billion GME dollars spent each year, $0 are allocated to GME funding for APPs. The direct consequence of this is a corresponding lack of formal neurology training programs for APPs (17). Nationally, there is only one known neurology GME program for APPs. That program has only two positions; not enough to staff that health system’s own demand for these clinicians. Here again, the incentive model has not adapted to the changes in healthcare – in this case the increasing need for APPs. A large commercial insurance plan with top five market share in a major U.S. metroplex lacks the contracting mechanism to allow in-network physicians to add their APPs to the plan’s provider network. This impedes delivery of APP services to patients with this insurance plan. The AAN, the largest professional association of neurologists, only recently began supporting the addition of APPs to the neurology care team. With one known exception, physician training in neurology takes place in teaching programs that do not include APPs. Neurologists are not trained to work in teams with APPs. APPs are not formally trained to work in neurology. Although the National Center for Health Workforce Analysis projects substantial Page 5 of 25 growth in APP presence in the neurology workforce by 2025 (5), there will still be a shortage in neurology. In summary, the neurology workforce supply is constrained from many sides. Factors including government policy, advances in neurological care, demographic changes, failure to innovate, and changing clinician work/life balance expectations are limiting growth in the supply of neurology patient care. But it is the convergence with another force – demand expansion – that is creating the perfect storm. B. Demand Expansion Demand expansion in neurology is more straightforward than supply constraints. As the growth of the neurology workforce is constrained, advances in treatment for neurological conditions and longer life expectancy increase the demand for neurology services. As life expectancy increases, more people develop neurological conditions. Parkinson’s disease, stroke, Alzheimer’s and other types of dementia are significantly